Impact of the COVID-19 pandemic on the severity and management of acute appendicitis.

Background: The literature seems to indicate that the number of appendectomies dropped at the beginning of the coronavirus disease in 2019 (COVID-19 pandemic), while the number of complicated appendicitis increased due to late presentation. In addition, a longer delay before surgical treatment resulted in a higher morbidity. This study aims to compare the number of appendectomies, the severity, and the management of acute appendicitis during the first two pandemic peaks of COVID-19 with those observed during the same seasonal periods in the previous 2 years in a regional hospital in Switzerland. Methods: We retrospectively reviewed and compared the number of appendectomies, rate of complicated appendicitis, delay to consultation and to surgery, distribution of appendectomies over a 24-h schedule, postoperative outcomes, and rates of overall complications in 177 patients, that is, 66 during the COVID-19 pandemic and 111 before the pandemic. Results: No statistical difference was found in the number of appendectomies, duration of symptoms before consultation, median time to surgery, number of appendectomies performed outside the usual scheduled time for non-urgent surgery, length of postoperative stay, or the rates of overall complications. However, there was a trend in the rate of complicated appendicitis (p = .05). Conclusion: In spite of a high incidence rate of COVID-19 in our canton, the impact of COVID-19 on our population did not follow the pattern observed elsewhere. The reasons for this might be that people would still present to the emergency department due to less strict social distancing measures. Great availability of emergency operating room may also account for the unchanged delay preceding surgical treatment and complication rates.

Degenerated Serous Cystic Tumor of the Pancreas: Case Report and Literature Review of an Aggressive Presentation of a Benign Tumor.

BACKGROUND Serous cystic tumors of the pancreas are known to present a benign nature and course, not requiring surgery in the absence of symptoms. In rare cases, these benign tumors may present aggressive characteristics such as local infiltration and lymph node and distant metastases. In such cases, a surgical approach may be necessary. CASE REPORT We present the case of a 79-year-old woman with an asymptomatic cytologically suggested caudal serous cystic tumor infiltrating the spleen and the splenic vein. This tumor was discovered in a computed tomography scan in the setting of evaluating distant spreading of a primary malignant neoplasm of the rectum. Suspicious malignant signs on imaging dictated a surgical approach and a distal splenopancreatectomy was carried out in the same operative time as the transanal resection of the rectal lesion. The nature of the pancreatic neoplasm was confirmed by histology, but 2 lymph nodes out of 4 retrieved were positive. The postoperative course was uneventful. No adjuvant treatment was proposed. Imaging control 6 months after surgery was not indicative of relapse. CONCLUSIONS Serous cystic adenomas of the pancreas, although generally considered benign neoplasms, may present with characteristics of malignancy. Moreover, they may prove difficult to differentiate from other malignant neoplasms by non-surgical modalities. Although current guidelines and data from the literature provide controversial information regarding management of these clinical entities, in the presence of suspicious radiological aspects, surgical resection could be considered.

Incarcerated Small-Bowel Pericardial Diaphragmatic Hernia After Pericardio-Peritoneal Window Creation: Report of a Rare Case.

BACKGROUND Pericardio-peritoneal windows are surgically created to treat symptomatic pericardial effusion, usually of oncological origin, to alleviate cardiac tamponade-like symptoms. Common complications include infection, failure to drain the fluid correctly, and arrythmias. There are few published cases of intra-abdominal complications due to these interventions. This report discusses pericardial diaphragmatic incarcerated hernia, which is one such complication. CASE REPORT We report the case of an 84-year-old woman with advanced non-small cell lung carcinoma, who recently underwent surgery to create a pericardio-peritoneal window to treat a chronic malignant pericardial effusion. The patient presented in our Emergency Department because of abdominal pain with absence of flatus and stool for more than 4 days. Computed tomography scanning confirmed a proximal small-bowel obstruction due to incarcerated small bowel into the pericardial window. Reduction of the hernia was performed laparoscopically. After a bowel viability assessment by indocyanine green angiography, the pericardial window was covered by a noncovered macroporous mesh to avoid recurrence and to allow continuous pericardial fluid drainage. CONCLUSIONS In case of abdominal pain after the creation of a pericardio-peritoneal window, we suggest the prompt use of computed tomography after initial examination. Indeed, although rare, a pericardial diaphragmatic hernia is possible and requires surgical exploration if there is a risk of bowel strangulation. The operation can be done laparoscopically, and the hernia repair should involve the placement of a nonabsorbable and noncovered macroporous mesh. This should prevent hernia recurrence, while also allowing adequate drainage of the pericardial effusion.

Fluorescence-based bowel anastomosis perfusion evaluation: results from the IHU-IRCAD-EAES EURO-FIGS registry.

BACKGROUND: Anastomotic leakage (AL) is one of the dreaded complications following surgery in the digestive tract. Near-infrared fluorescence (NIRF) imaging is a means to intraoperatively visualize anastomotic perfusion, facilitating fluorescence image-guided surgery (FIGS) with the purpose to reduce the incidence of AL. The aim of this study was to analyze the current practices and results of NIRF imaging of the anastomosis in digestive tract surgery through the EURO-FIGS registry. METHODS: Analysis of data prospectively collected by the registry members provided patient and procedural data along with the ICG dose, timing, and consequences of NIRF imaging. Among the included upper-GI, colorectal, and bariatric surgeries, subgroup analysis was performed to identify risk factors associated with complications. RESULTS: A total of 1240 patients were included in the study. The included patients, 74.8% of whom were operated on for cancer, originated from 8 European countries and 30 hospitals. A total of 54 surgeons performed the procedures. In 83.8% of cases, a pre-anastomotic ICG dose was administered, and in 60.1% of cases, a post-anastomotic ICG dose was administered. A significant difference (p < 0.001) was found in the ICG dose given in the four pathology groups registered (range: 0.013-0.89 mg/kg) and a significant (p < 0.001) negative correlation was found between the ICG dose and BMI. In 27.3% of the procedures, the choice of the anastomotic level was guided by means of NIRF imaging which means that in these cases NIRF imaging changed the level of anastomosis which was first decided based on visual findings in conventional white light imaging. In 98.7% of the procedures, the use of ICG partly or strongly provided a sense of confidence about the anastomosis. A total of 133 complications occurred, without any statistical significance in the incidence of complications in the anastomoses, whether they were ICG-guided or not. CONCLUSION: The EURO-FIGS registry provides an insight into the current clinical practice across Europe with respect to NIRF imaging of anastomotic perfusion during digestive tract surgery.

[Proctological emergencies in pregnant women]. / Les urgences proctologiques chez la femme enceinte.

Hemorrhoids affect up to 85 % of pregnant women during the last two trimesters. The maximum incidence for anal fissure is 20 %. One of the common risk factors is constipation promoted during pregnancy. The history of anal pathology, the length of delivery and the baby's birth weight also promote these two entities. The treatment includes above all hygiene and dietary measures to prevent constipation and conservative measures (local anesthetics, sitz baths). Surgical procedures should be avoided and indicated only in case of failure of conservative treatment. Rectal prolapse is more rare and must be reduced manually before surgery. Measures to prevent constipation also apply.

Les hémorroïdes concernent jusqu'à 85 % des femmes enceintes durant les deux derniers trimestres. L'incidence maximale pour la fissure anale atteint 20 %. Un des facteurs de risque communs est la constipation favorisée durant la grossesse. Les antécédents de pathologies anales, la durée de l'accouchement et le poids de naissance du bébé favorisent aussi ces deux entités. Le traitement comprend avant tout des mesures hygiéno-diététiques pour prévenir la constipation et des mesures conservatives (anesthésiants locaux, bains de siège). Les interventions chirurgicales sont à éviter et indiquées uniquement en cas d'échec du traitement conservateur. Le prolapsus rectal est plus rare et doit être réduit manuellement avant une intervention chirurgicale à réaliser en postpartum. Les mesures de prévention de la constipation s'appliquent également.

Surgical management and long-term outcome of complicated liver hydatid cysts caused by Echinococcus granulosus.

BACKGROUND: The aim of this retrospective study was to evaluate clinical presentation and long-term outcome of patients treated surgically for complicated liver hydatid cysts. PATIENTS AND METHODS: Eighty-four patients with liver hydatid cysts underwent an operation at the Geneva University Hospital between 1980 and 1999. Clinical presentation, postoperative morbidity, mortality, and long-term recurrence rate were evaluated. RESULTS: Among the 84 patients with liver hydatid disease, 35 patients (41%) presented complicated cysts (ie, cysts that had developed a fistula into adjacent structures or organs). In most patients, the fistula communicated with the biliary tree (n = 25), but we also observed communication with the right lung (n = 3), the right diaphragm (n = 2), liver parenchyma (n = 1), and peritoneal cavity (n = 1). Complete removal of the cystic disease was possible in 24 of 35 patients (70%). In 11 patients, fragments of cysts were not removed because of their location adjacent to main vessels. Postoperatively, 8 patients (23%) developed a severe complication (grade II and III). There were no postoperative deaths, and no recurrences of hydatid disease were observed with a median follow-up of 8.6 years (complete follow-up was obtained in 69% of patients). CONCLUSIONS: Complicated liver hydatid disease is frequent and was observed in almost half of patients operated for liver hydatid cysts at our center. Using a surgical strategy aimed at complete removal of cystic and pericystic tissue with simultaneous treatment of the fistulous tract, we observed 23% postoperative morbidity, no mortality, and no recurrence of disease with a median follow-up of >8 years.

Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases.

PURPOSE: The aim of of this study was to evaluate prospectively the long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon. METHODS: Between October 1986 and October 1997, a total of 465 patients urgently admitted to our hospital with a suspected diagnosis of acute left-sided colonic diverticulitis had a CT scan. Of 76 patients (17 percent) who had an associated mesocolic or pelvic abscess, 3 were lost to follow-up. The remaining 73 patients (45 with a mesocolic abscess and 28 with a pelvic abscess) were followed for a median of 43 months. RESULTS: of the 45 patients with a mesocolic abscess, 7 (15 percent) required surgery during their first hospitalization versus 11 (39 percent) of the 28 patients with a pelvic abscess (P = 0.04). At the end of follow-up, 22 (58 percent) of the 38 patients with a mesocolic abscess who had successful conservative treatment during their first hospitalization did not need surgical treatment vs. 8 (47 percent) of the 17 who had a pelvic abscess. Altogether, 51 percent of the patients with a mesocolic abscess had surgical treatment versus 71 percent of those with a pelvic abscess (P = 0.09). CONCLUSIONS: Considering the poor outcome of pelvic abscess associated with acute left-sided colonic diverticulitis, percutaneous drainage followed by secondary colectomy seems justified. Mesocolic abscess by itself is not an absolute indication for colectomy.

Long term results after complete or incomplete surgical resection of liver hydatid disease.

BACKGROUND: The liver is the organ most frequently infected by hydatid disease and medical therapy alone is ineffective in eliminating the parasite. Surgical options vary from complete resection (e.g. total pericystectomy or hepatectomy) to limited procedures (e.g. percutaneous aspiration or unroofing of cysts). The aim of this study was to determine the long-term outcome after complete or partial resection of liver hydatid cysts. PATIENTS AND RESULTS: Between 1980 and 1996, 78 patients were operated upon at our institution for liver hydatid cysts. In Group 1, complete resection was achieved in 57 patients (73 %), whereas in Group 2, incomplete resection was performed in 21 patients (27 %), due to multiplicity, bilaterality of cysts or close contact between a cyst and portal or hepatic veins. The post-operative morbidity in Groups 1 and 2, was 31 % and 47 % (N.S.), respectively. Mean duration of hospital stay was 17 and 26 days (p=0.004), respectively. Recurrence rate of hydatid disease after a mean follow-up of 6.6 years was 0 % and 12% (N.S.), respectively. There was no mortality in either group. CONCLUSIONS: Complete surgical resection of hepatic hydatid disease should be attempted whenever possible. Our results, with a mean follow-up of 6.6 years, indicate limited post-operative debilitating complications, low recurrence rate and no mortality.